Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries
Authors: Niloofar Dehghan, Aaron Nauth, Emil Schemitsch, Milena Vicente, Richard Jenkinson, Hans Kreder, Michael McKee, Jeremy Hall, Avery Nathens, Andrew Baker, Sandro Rizoli, Brian Pollard, Jennifer Hidy, Christine Schemitsch, Paril Suthar, Melanie MacNevin, Syed Morad Hameed, Emilie Joos, Gerard P Slobogean, Shelley Abercromby, Richard Malthaner, Dalilah Fortin, Abdel Lawendy, Deb Lewis, Andrew Furey, Craig Stone, Sarah Anthony, Valisha Keough, Minnie Parsons, Erin Baker, David Stephen, Patrick Henry, Lorraine Tremblay, Homer Tien, Katrine Milner, Monica Kunz, Wesley Ghent, Aimee Theriault, Araby Sivananthan, Fathima Adamsahib, Katerina Polihronidis, Mopina Shrikumar, Brad A Petrisor, Bill Ristevski, Dale Williams, Paul Engels, Jamal Al-Asiri, Herman Johal, Nicole Simunovic, Jenna Ratcliffe, Jordan Leonard, Sarah Crouch, Hiba Abdul Mannan, Sofia Bzovsky, Matthew Skelly, Francesc A Marcano-Fernández, Robert Korley, Paul Duffy, Prism Schneider, Ryan Martin, Richard Buckley, Leah Kennedy, Aftab Akbari, Stephanie Yee, Tanja Harrison, Ted V Tufescu, Sadeesh Srinathan, Brad Pilkey, Chris Graham, Nigar Sultana, Ramon Angeles, Edward Harvey, Gregory Berry, Rudolf Reindl, Max Talbot, Mitchell Bernstein, Kosar Khwaja, Lorenzo Ferri, Tarek Razek, Dan Deckelbaum, Jonathan Spicer, Jeremy Grushka, Andrew Beckett, Mary Amedeo, Josie Campisi, Norine Alam, Allan Liew, Steven Papp, Wade Gofton, Karl-Andre Lalonde, Guiseppe Pagliarello, Jean Denis Yelle, Julia Foxall, Nicole Harris, Peter Cole, Paul Lafferty, Sandy Vang, Clifford Jones, Terence Endres, Dennis Gregory, Donald Scholten, Debra Sietsema, Jane Walker, Michelle A Padley, Lindsey Behrend, Eduardo Smith Singares, Ellen Omi, Diane Lelo, Lisa Chamberlain, Diane Braun, Nicole M Floyd, Drew Fielder, Daniel L Stahl, Kevin Thorpe, Peter Juni, Bruno Da Costa, Mohit Bhandari, Jeffrey Singh, Mary-Anne Aarts, Kim Madden
Journal: JAMA Surgery (2022)

Importance Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking. Objective To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management. Design, Setting, and Participants This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non–flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021. Interventions Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment. Main Outcomes and Measures The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy). Results A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, −0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment. Conclusions and Relevance The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated. Trial Registration ClinicalTrials.gov Identifier: NCT01367951